Forms for providers
USTEPS and UPI Access Forms
- 0-1 DSPD Employee USTEPS ACCESS Form
- 0-2 USTEPS Support Coordinator Contracted Provider Access Request Form
- 0-3 Individual User Email Change Request Form
- 0-5 Private Support Coordinator Company Access Request Form
- 0-8 USTEPS Provider Interface (UPI) Individual User Access Form
- 0-9 USTEPS Provider Interface (UPI) Provider Company Designee Access Form
- 0-10 Provider Company Email Change Request Form
Deceased Client Report Form
Invitation to Submit Offer to Provide Services Forms
- 1-6 Invitation to Submit Offer to Provide Services (PDF)
- 1-6 Invitation to Submit Offer to Provide Services (Word Version)
Division and Department Codes of Conduct:
- Division of Services for People with Disabilities Code of Conduct
- Department of Human Services Code of Conduct
- 5-3 Code of Conduct Certification
Supported Work Independence Program:
- 201 Supported Work Independence Client Information Form
- 202 Supported Work Independence Participation Agreement
- 203 Community Services Brokering Action Plan
Miscellaneous Forms
- Certified Provider Background Screening Application
- Youth Background Screening Application
- Certified Provider Background Screening Application Instructions
- DHS Conflict of Interest – Declaration Form
- 1-2 Authorization to Furnish Information and Release from Liability
- 1-2A Release of Information
- 1-3 Voluntary Financial Support Agreement
- 1-18 Request to Amend or Add to Record
- 1-19 Evaluation for ESMC Waiting List One-Time Funded Services
- 101 In-Home Treatment Exception Request – Medicaid Autism Waiver
- 295 CAPS Form – One-Time Payment Form
- One Time Payment Process
- 295A One-Time Payment Process Pre Purchase Assessment
- 520 Provider Service Invoice
- 801 PASRR Categorical Determination
- 802 PASRR Individualized Determination
- 902 Physical Examination Report
- 928 Exceptional Needs Prior Authorization for Residential Habilitation
- 929 Respite – Intensive Screening
- 930 Enhanced Supervision & Rate Form
- 930a Guidelines for Enhanced Staffing & Rates
- ICF/ID Transition Fact Sheet